Summary Plan Description UNITEDHEALTHCARE HEALTH REIMBURSEMENT ACCOUNT PLAN FOR Tulane University Effective: January 1, 2014 Group Number: 755807
Notice To Employees HEALTH REIMBURSEMENT ACCOUNT (HRA) PLAN This booklet describes the Employer-sponsored Health Reimbursement Account Plan as of January 1, 2014. Tulane University has entered into an arrangement with United HealthCare Services, Inc., Minnetonka, MN ("UnitedHealthcare") under which UnitedHealthcare will process reimbursements and provide certain other administrative services to the Plan. UnitedHealthcare does not insure the benefits described in this booklet.
TABLE OF CONTENTS SECTION 1 - WELCOME - HRA... 1 What is a Health Reimbursement Account?... 2 SECTION 2 - INTRODUCTION TO THE HRA... 4 Who Is Eligible for the HRA And How To Enroll... 4 Cost of Coverage... 4 Changing Your HRA Coverage... 5 SECTION 3 - HOW THE HRA PLAN WORKS... 6 How much money is allocated to your HRA Employer Contributions... 6 New Hires And Adjustments For Status Changes... 6 What Type of Medical Expenses Qualify for Reimbursement From The HRA... 7 What happens to remaining balances in the HRA... 7 Section 4 - HRA CLAIMS PROCEDURES... 8 Claims Submission... 8 Network Benefits... 8 Non-Network Benefits... 8 When to Submit a Claim... 9 How to File Your Claim for Reimbursement from the HRA... 9 Health Statements... 10 Explanation of Benefits (EOB)... 10 Requesting Reimbursement from Your HRA... 10 Claim Denials and Appeals... 11 Limitation of Action... 13 SECTION 5 - HRA COORDINATION OF BENEFITS (COB) AND SUBROGATION AND REIMBURSEMENT... 14 Overpayment and Underpayment of Benefits... 14 Subrogation and Reimbursement... 14 SECTION 6 - WHEN HRA COVERAGE ENDS... 15 Continuation of Coverage - Consolidated Omnibus Budget Reconciliation Act ("COBRA")... 15 Uniformed Services Employment and Reemployment Rights Act... 15
SECTION 7 - HRA GLOSSARY... 17 SECTION 8: HRA ADMINISTRATIVE INFORMATION: ERISA... 20
SECTION 1 - WELCOME - HRA Quick Reference Box Member services and claim inquiries, use the Customer Service number on the back of your ID card or call 1-800-331-0480; HRA Claims submittal address: Health Care Account Service Center, PO Box 981506, El Paso, TX 79998-1506; and Online assistance: www.myuhc.com Tulane University is pleased to provide you with this Summary Plan Description (SPD), which describes the Health Reimbursement Account (HRA) available to you and your eligible dependents enrolled in the Plan. A Health Reimbursement Account is a financial account that allows Tulane University to reimburse you for "qualified" health expenses paid by you, under the associated medical plan, to offset health care costs. The HRA maximizes the value of your health care dollars, and allows you to become more engaged in managing health care spending. We offer several online tools to help you make more informed health care decisions and manage your HRA account balance, visit www.myuhc.com for access to health and wellness resources or the Treatment Cost Estimator. Once you spend your entire HRA fund balance, you are responsible for paying expenses as described in your medical plan Policy. You can keep track of the funds in your HRA by going online to www.myuhc.com, by calling the toll-free number on the back of your ID card or by checking your monthly member statement sent to you by UnitedHealthcare. The HRA SPD is designed to meet your information needs specific to the financial account, not the medical plan that it is associated with, and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed SPD or electronic SPD for the financial account component of the Plan. This SPD includes summaries of: Eligibility and enrollment; What the HRA is and how it works; What health expenses may be eligible for reimbursement; Claims processing, Appeals and Denials; and Your rights and responsibilities under the Plan. 1 SECTION 1 - WELCOME - HRA
Tulane University intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary. UnitedHealthcare is a private healthcare claims administrator. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Tulane University is solely responsible for paying Benefits described in this SPD. Please read this SPD thoroughly to learn how the financial account component of the Plan works. Capitalized terms not otherwise defined in this SPD have the meaning set forth in your medical plan COC. If you have questions contact your Benefits Representative or call the number on the back of your ID card. What is a Health Reimbursement Account? Health Reimbursement Account's are "unfunded" accounts; otherwise known as a demand deposit account. The Tulane University is not required to prepay into it, instead, funds allocated to the HRA are made available to reimburse you for your claims as they occur. All contributions allocated to your HRA are owned, controlled and payable solely from the general assets of Tulane University. You are not permitted to make any contribution to this HRA, whether made on a pre-tax or after-tax basis. In addition: The HRA is established by Tulane University and administered by UnitedHealthcare in accordance with applicable provisions of the Internal Revenue Service Code and associated guidance issued by the IRS/Treasury Department. Tulane University determines which Internal Revenue Code 213d health expenses will be eligible for reimbursement through the HRA. Reimbursements of HRA Eligible Expenses are tax-deductible for Tulane University. There is no limit to the contributions Tulane University can choose to allocate to your account. Employer Contributions allocated to your HRA can be excluded from your gross income. Tulane University will decide how to handle any unused funds at the end of the calendar year. Unused funds are not transferable if your employment with Tulane University ends. 2 SECTION 1 - WELCOME - HRA
How To Use This SPD Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference. Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section. You can find copies of your SPD and any future amendments or request printed copies by contacting your Benefits Representative. Capitalized words in the SPD have special meanings and are defined in Section 7, HRA Glossary. If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 7, HRA Glossary. Tulane University is also referred to as Company. If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control. 3 SECTION 1 - WELCOME - HRA
SECTION 2 - INTRODUCTION TO THE HRA What this section includes: Who Is Eligible; Cost of Coverage; How To Enroll; and Coverage changes. Who Is Eligible for the HRA And How To Enroll You must be covered under the corresponding medical plan administered by UnitedHealthcare in order to participate in the HRA. You are enrolled in the HRA at the same time you enroll in your medical plan. You cannot elect it separately and you can t withdraw from it unless you also withdraw from the medical plan. Eligibility to participate in the Plan is described in the medical plan Policy. Contact your Benefits Representative if you have questions about eligibility and enrollment. Each year during annual Open Enrollment, you have the opportunity to review and change your benefit election. Any changes you make during Open Enrollment will become effective as described in the medical plan Policy. Important If you wish to change your benefit elections following a marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact your Benefits Representative as described in the medical plan Policy. Otherwise, you will need to wait until the next annual Open Enrollment to change your elections. Cost of Coverage You and Tulane University share in the cost of the medical plan, there is no charge to you for participation in the financial account component of your Plan. Your contribution amount, (also known as a premium) depends on the medical plan you select and the family members you choose to enroll. Your medical plan premium is deducted from your paychecks on a before-tax basis. Beforetax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. Note: The Internal Revenue Service generally does not consider Domestic Partners eligible Dependents. Therefore, the value of Tulane University's cost in covering a Domestic Partner may be imputed to the Subscriber as income. In addition, the share of the Subscriber's contribution that covers a Domestic Partner may be paid using after-tax payroll deductions. Your contributions are subject to review and Tulane University reserves the right to change your contribution amount from time to time. 4 SECTION 2 - INTRODUCTION TO THE HRA
You can obtain current premium rates by calling your Benefits Representative. Changing Your HRA Coverage If you are hired during the Plan year or are enrolling in the Plan mid-year during a special enrollment period, coverage will become effective as described in the medical plan Policy. For detail on the Employer Contribution to your HRA for mid-year enrollment and/or status changes see Section 3 - How the Plan Works under the heading New Hires and Adjustments for Status Changes in this SPD. For information on ending your coverage please refer to Section 6 - When HRA Coverage Ends. 5 SECTION 2 - INTRODUCTION TO THE HRA
SECTION 3 - HOW THE HRA PLAN WORKS What this section includes: How much money is allocated to your HRA - Employer Contributions; New Hires And Adjustments For Status Changes; What Type of expenses Qualify for Reimbursement from the HRA; and What happens to remaining balances in the HRA. How much money is allocated to your HRA Employer Contributions Tulane University will allocate a specified amount of funds to your HRA on a calendar year basis specific to the coverage category you enroll in. For each claim presented to the HRA, available funds will be used to pay for HRA Eligible Expenses. Coverage Category Annual Employer Contribution to your HRA 1 Access Point 1,2 (What You Pay First Before The HRA Is Active) individual $500 $1,000 family 3 $1,000 $2,000 1The amounts you pay toward your Access Point accumulate over the course of the calendar year. 2HRA Eligible Expenses charged by Network providers apply towards the HRA Access Point. 3Each covered member has an individual Access Point within the Family Access Point. Once it has been reached, that particular member's claim can be paid out of the HRA. Once the Family Access Point has been reached, all members' claims can be paid out of the HRA. Only dollars are applied toward meeting the Individual Access Point (dollars paid out of pocket) will accumulate towards the Family Access Point. New Hires And Adjustments For Status Changes Mid-Year Enrollment If you are hired during the Plan year or are enrolling in the Plan mid-year during a special enrollment period as a result of a change in status, the amount of the Employer Contribution allocated to your HRA will not be prorated. Status Changes When you switch among Coverage Categories the Tulane University's contribution amount allocated to your HRA may increase or decrease by category. Under the Plan, if you increase your category (e.g. individual to family) the Employer Contribution to your HRA is adjusted to your new category for that Plan year minus any amounts already accumulated or used in that Plan year. 6 SECTION 3 - HOW THE HRA PLAN WORKS
If you decrease your category (e.g. you change from family to individual) the Employer Contribution to your HRA is adjusted to your new category for that Plan year minus any amounts already accumulated or used in that Plan year. The amount in your HRA can not have a negative balance. Reinstatement without a break in coverage. Following a termination, if you are rehired by Tulane University, can you be reinstated without experiencing any break in coverage? No, your HRA Plan does not allow reinstatement without experiencing any break in coverage. When you are rehired by Tulane University and re-enroll in the active medical plan and the HRA Plan the HRA Contribution amount will equal the amount a newly hired active employee would be eligible for. (See this Section under the heading Mid-Year Enrollment. Reinstatement with a break in coverage. Are you able to recover funds after a break in employment? Yes, you can use prior accumulated balances after re-enrollment as a result of a break in employment. When you are rehired by Tulane University within 3 months following your employment termination date and re-enroll in the active medical plan and the HRA Plan the HRA Contribution amount will equal the balance you held in your HRA on the day prior to your employment termination date. You can keep track of the funds in your HRA by going online to www.myuhc.com, by calling the toll-free number on the back of your ID card or by checking your monthly member statement sent to you by UnitedHealthcare. What Type of Medical Expenses Qualify for Reimbursement From The HRA Not all health-related expenses qualify for reimbursement under the HRA Plan. Section 213(d) of the Internal Revenue Code of 1986, as amended from time to time defines what health care expenses are considered "qualified" medical expenses for federal income tax purposes. Only amounts that are paid specifically to reimburse eligible medical care expenses, as defined in Section 213(d), will be covered under the HRA Plan. Your Employer has determined which of those "qualified" medical expenses will be considered HRA Eligible Expenses under your Plan and reimbursable from your HRA. Under your Plan, the HRA reimburses all amounts due from claims for medical expenses that are eligible from the underlying medical plan. Allowable expenses include the Annual Deductible. What happens to remaining balances in the HRA If you don't spend all the funds in your HRA during the initial calendar year, and you reenroll in the Plan for the following year, you forfeit any unused funds remaining in the account. If you don t re-enroll in the Plan for the following year, you forfeit any unused funds remaining in the account. 7 SECTION 3 - HOW THE HRA PLAN WORKS
SECTION 4 - HRA CLAIMS PROCEDURES What this section includes: How HRA claims payments work; Requesting Reimbursement from Your HRA; and What to do if your claim is denied, in whole or in part. Claims Submission Tulane University has designed your HRA to allow certain claims to be automatically submitted to your account for reimbursement. UnitedHealthcare will coordinate payments from your HRA for medical claims only. There are some types of claims that will not be processed automatically for which you will need to submit a claim; for additional information on these claims see the header below called When to Submit a Claim. When auto-submission is elected all payments from an HRA will be sent to the provider directly. You will receive the reimbursement when no provider information is available. In the 2 situations listed below, you will receive reimbursement from the HRA: Manually submitted claims. Claims adjustments. Note The Plan's Access Point must be first met before reimbursement will be made from the HRA. Network Benefits In general, if you receive Covered Health Services from a Network provider, UnitedHealthcare will process the payment for the medical plans portion of the cost of the Covered Health Services and send it directly to the Physician or facility. Funds allocated to your HRA will be available to help you pay a portion of your out-ofpocket costs under the medical plan as described in this SPD in Section 3 - How the Plan Works. UnitedHealthcare will process the payment for a portion of your cost of the Covered Health Services from available funds in your HRA and send it directly to the Physician or facility automatically. This feature can be turned on and off by accessing myuhc.com. There are some types of claims that will not be paid directly to the provider. They are as follows: manually submitted claims and adjustments. These types of claims will always pay you directly. Non-Network Benefits Non-Network Benefits are not eligible for reimbursement under your plan except for a non- Network provider as a result of an Emergency. If you receive a bill for Covered Health 8 SECTION 4 - HRA CLAIM PROCEDURES
Services from a non-network provider as a result of an Emergency, you (or the provider if they prefer) must send the bill to UnitedHealthcare for processing. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare at the address on the back of your ID card. If you receive Covered Health Services from a non-network provider funds from your HRA will automatically be reimbursed to you, up to the amount available in your HRA after having met your HRA Access Point. You will only be reimbursed from your HRA for expenses incurred while you are a Covered Person under the Plan. When to Submit a Claim When Auto-rollover feature does not apply, you must submit a claim for reimbursement from your HRA. If you receive a bill for Covered Health Services from a provider, you must send the bill to UnitedHealthcare for processing. Important - Timely Filing of Non-Network Claims All claim forms for non-network claims must be submitted within 12 months after the date of service. Otherwise, the Plan will not pay any Benefits for that Eligible Expense, or Benefits will be reduced, as determined by Employer Legal Name. This 12-month requirement does not apply if you are legally incapacitated. How to File Your Claim for Reimbursement from the HRA To be reimbursed from your HRA simply submit a reimbursement form, called a Request for Withdrawal Form, for the HRA Eligible Expenses that have been incurred. A Request for Withdrawal Form is available from Tulane University or on the Internet at www.myuhc.com. For reimbursement from your HRA, you must include proof of the expenses incurred as indicated on the Request for Withdrawal Form. For HRA Eligible Expenses, proof can include a bill, invoice, or an Explanation of Benefits (EOB) from any group medical plan under which you are covered. An EOB will be required if the expenses are for services usually covered under group medical plans, for example, charges by surgeons, doctors and hospitals. In such cases, an EOB will verify what your out-of-pocket expenses were after payments under other group medical plans. To make sure the claim is processed promptly and accurately, a completed claim form must be attached and mailed to UnitedHealthcare HRA Claims submittal address: Health Care Account Service Center PO Box 981506 El Paso, TX 79998-1506 Important You can view EOB's and Health Statements online via myuhc.com. Myuhc.com includes many features such as the option to: View your HRA summary page detailing contributions and amount left in your HRA; 9 SECTION 4 - HRA CLAIM PROCEDURES
View your HRA Claims Summary including claim transaction details. Health Statements Each month in which UnitedHealthcare processes at least one claim for you or a covered Dependent, you will receive a Health Statement in the mail. Health Statements make it easy for you to manage your family s medical costs by providing claims information in easy-tounderstand terms. If you would rather track claims for yourself and your covered Dependents online, you may do so at www.myuhc.com. You may also elect to discontinue receipt of paper Health Statements by making the appropriate selection on this site. Explanation of Benefits (EOB) You may request that UnitedHealthcare send you a paper copy of an Explanation of Benefits (EOB) after processing the claim. The EOB will let you know if there is any portion of the claim you need to pay. If any claims are denied in whole or in part, the EOB will include the reason for the denial or partial payment. If you would like paper copies of the EOBs, you may call the toll-free number on your ID card to request them. You can also view and print all of your EOBs online at myuhc.com. See Section 7, HRA Glossary for the definition of Explanation of Benefits. Requesting Reimbursement from Your HRA If you have allocated funds available in your HRA you may submit a claim for reimbursement for the HRA Eligible Expenses from your HRA. If you do choose to submit a request for reimbursement for Network claims, the request must be received no later than 90 days following the end of the calendar year in which you are eligible under this Plan. All claim forms for non-network claims must be submitted within 365 days of the date of service. If you don't provide this information to the Claims Administrator within this timeframe, your claim will not be eligible for reimbursement, even if there are funds available in your HRA. This time limit does not apply if you are legally incapacitated. You will be reimbursed for HRA Eligible Expenses. You cannot be reimbursed for any expense paid under your medical plan, and any expenses for which you are reimbursed from your HRA cannot be included as a deduction or credit on your federal income tax return. Important Note The date on which you incurred an Eligible Medical Expense is used when deducting funds from your HRA. This allows the funds in your HRA to act like a savings account, available for your use when your claim is paid. 10 SECTION 4 - HRA CLAIM PROCEDURES
Claim Denials and Appeals If Your Claim is Denied If a claim for benefits is denied in part or in whole, you may call UnitedHealthcare at the number provided by Tulane University before requesting a formal appeal. If UnitedHealthcare cannot resolve the issue to your satisfaction over the phone, you have the right to file a formal appeal as described below. How to Appeal a Denied Claim If you wish to appeal a denied claim, you must submit your appeal in writing within 180 days of receiving the denial. This written communication should include: the patient's name and ID number as shown on the ID card; the provider's name; the date of medical service; the reason you think your claim should be paid; and any documentation or other written information to support your request. If you wish to request a formal appeal of a denied claim for reimbursement, you should call the number provided by Tulane University to obtain the UnitedHealthcare address where the appeal should be sent. For Urgent Care claims that have been denied, you or your provider can call UnitedHealthcare at the toll-free number on your ID card to request an appeal. Appeals for your HRA should be submitted to: UnitedHealthcare HRA Group Claims PO Box 981178 El Paso, TX 79998-11178 Review of an Appeal UnitedHealthcare will conduct a full and fair review of your appeal. The appeal may be reviewed by: an appropriate individual(s) who did not make the initial benefit determination; and a health care professional who was not consulted during the initial benefit determination process. Once the review is complete, if UnitedHealthcare upholds the denial, you will receive a written explanation of the reasons and facts relating to the denial. Filing a Second Appeal Your Plan offers two levels of appeal. If you are not satisfied with the first level appeal decision, you have the right to request a second level appeal from Tulane University within 11 SECTION 4 - HRA CLAIM PROCEDURES
60 days from receipt of the first level appeal. Tulane University must notify you of the benefit determination within 30 days after receiving the completed appeal. Note: Upon written request and free of charge, any covered persons may examine documents relevant to their claim and/or appeals and submit opinions and comments. Tulane University will review all claims in accordance with the rules established by the U.S. Department of Labor. Tulane University's decision will be final. The table below describes the time frames in an easy to read format which you and UnitedHealthcare are required to follow. Claim Denial and Appeals Type of Claim or Appeal If your claim is incomplete, UnitedHealthcare must notify you within: You must then provide completed claim information to UnitedHealthcare within: Timing 30 days 45 days after receiving an extension notice * If UnitedHealthcare denies your initial claim, they must notify you of the denial: if the initial claim is complete, within: 30 days after receiving the completed claim (if the initial claim is incomplete), within: You must appeal the claim denial no later than: UnitedHealthcare must notify you of the first level appeal decision within: You must appeal the first level appeal (file a second level appeal) within: Tulane University must notify you of the second level appeal decision within: 30 days 180 days after receiving the denial 30 days after receiving the first level appeal 60 days after receiving the first level appeal decision 30 days after receiving the second level appeal *UnitedHealthcare may require a one-time extension of no more than 15 days only if more time is needed due to circumstances beyond their control. 12 SECTION 4 - HRA CLAIM PROCEDURES
Limitation of Action You cannot bring any legal action against Tulane University or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Tulane University or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Tulane University or the Claims Administrator. You cannot bring any legal action against Tulane University or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Tulane University or the Claims Administrator you must do so within three years of the date you are notified of the final decision on your appeal or you lose any rights to bring such an action against Tulane University or the Claims Administrator. 13 SECTION 4 - HRA CLAIM PROCEDURES
SECTION 5 - HRA COORDINATION OF BENEFITS (COB) AND SUBROGATION AND REIMBURSEMENT For information on how your Benefits under this Plan coordinate with other medical plans and how coverage is affected if you become eligible for Medicare, refer to the medical plan Policy. The HRA is considered part of your coverage. Overpayment and Underpayment of Benefits Coordination of Benefits (COB) applies to you if you are covered by more than one health benefits plan. For further information on COB refer to the medical plan Policy. Subrogation and Reimbursement The Plan has a right to subrogation and reimbursement, as defined in the Policy. 14 SECTION 5 - HRA COB AND SUBROGATION
SECTION 6 - WHEN HRA COVERAGE ENDS Your coverage under the Plan ends as described in the Policy. Continuation of Coverage - Consolidated Omnibus Budget Reconciliation Act ("COBRA") The requirements of the Consolidated Omnibus Budget Reconciliation Act ("COBRA") may apply to the Health Reimbursement Account. You should call Tulane University to find out whether this Plan is subject to COBRA. If the Plan is subject to COBRA see "Optional Continuation Coverage under your Health Care Spending Account (COBRA)". COBRA continuation coverage must be offered with respect to a participant's HRA when the Plan is subject to COBRA. If your employment terminates for any reason the funds in your HRA will revert back to us after your claim run-out period, unless you elect COBRA coverage as described in the Policy. If you elect COBRA coverage, HRA funds will remain available to assist you in paying your out-of-pocket costs under the medical plan while COBRA coverage is in effect. The HRA balances under COBRA are recalculated using the methods elected by Tulane University for mid-year enrollment and/or status changes; as described in Section 3 How the HRA Plan Works, under the heading New Hires and Adjustments for Status Changes. Optional Continuation Coverage Under Your Health Reimbursement Account This optional continuation coverage only applies if it has been made available by Tulane University. Tulane University may be required to offer this continuation coverage in certain cases as a result of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). This provision is intended to comply with the law and any pertinent regulations, and its interpretation is governed by them. Ask Tulane University to find out if and how this continuation coverage and continuation coverage under USERRA described below applies. In no event will UnitedHealthcare be obligated to provide continuation coverage to a participant if Tulane University or its designated plan administrator fails to perform its responsibilities under federal law. These responsibilities include but are not limited to notifying the participant in a timely manner of the right to elect continuation coverage and notifying UnitedHealthcare in a timely manner of the participant's election of continuation coverage. Uniformed Services Employment and Reemployment Rights Act An employee who is absent from employment for more than 30 days by reason of service in the Uniformed Services may elect to continue Plan coverage for the employee and the employee's dependents in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA). The terms "Uniformed Services" or "Military Service" mean the Armed Forces, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency. 15 SECTION 6 - WHEN HRA COVERAGE ENDS
If qualified to continue coverage pursuant to the USERRA, employees may elect to continue coverage under the Plan by notifying the Plan Administrator in advance, and providing payment of any required contribution (i.e., contributions to the account) for the HRA. If an employee 's Military Service is for a period of time less than 31 days, the employee may not be required to pay more than the regular contribution amount (i.e., contributions to the account), for continuation of the HRA.. An employee may continue Plan coverage under USERRA for up to the lesser of: the 24 month period beginning on the date of the employee's absence from work; or the day after the date on which the employee fails to apply for, or return to, a position of employment. Regardless of whether an employee continues the HRA, if the employee returns to a position of employment, the employee's HRA and that of the employee's eligible dependents will be reinstated under the Plan. No exclusions or waiting period may be imposed on an employee or the employee's eligible dependents in connection with this reinstatement, unless a Sickness or Injury is determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of military service. You should call the Plan Administrator if you have questions about your rights to continue the HRA under USERRA. UnitedHealthcare is not Tulane University's designated Plan Administrator and does not assume any responsibilities of a Plan Administrator pursuant to federal law. 16 SECTION 6 - WHEN HRA COVERAGE ENDS
SECTION 7 - HRA GLOSSARY What this section includes: Definitions of terms used throughout this SPD. Many of the terms used throughout this SPD may be unfamiliar to you or have a specific meaning with regard to the way the Plan is administered and how benefits are paid. This section defines terms used throughout this SPD, but it does not describe the benefits provided by the Plan. Capitalized terms not otherwise defined in this section have the meaning set forth in your medical plan COC. Addendum any attached written description of additional or revised provisions to the Plan. The benefits and exclusions of this SPD and any amendments thereto shall apply to the Addendum except that in the case of any conflict between the Addendum and SPD and/or Amendments to the SPD, the Addendum shall be controlling. Amendment any attached written description of additional or alternative provisions to the Plan. Amendments are effective only when distributed by the Plan Sponsor or the Plan Administrator. Amendments are subject to all conditions, limitations and exclusions of the Plan, except for those that the amendment is specifically changing. Annual Deductible (or Deductible) the amount you must pay for Eligible Expenses under a health plan, in the Plan year before the Plan will begin paying Benefits in that Plan year. Benefits Plan payments for Eligible Expenses, subject to the terms and conditions of the Plan and any Addendums and/or Amendments. Claims Administrator - HRA UnitedHealthcare (also known as United HealthCare Services, Inc.) and its affiliates, who provide certain claim administration services for the Plan. COBRA see Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Company Tulane University. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) a federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated. Covered Person either the Employee or an enrolled Dependent only while enrolled and eligible for Benefits under the Plan. References to "you" and "your" throughout this SPD are references to a Covered Person. Dependent an individual who meets the eligibility requirements specified under the Plan, as described in your medical plan Policy offered by Tulane University. Eligible Expenses as defined in your COC. 17 SECTION 7 - HRA GLOSSARY
Employer Tulane University. EOB see Explanation of Benefits (EOB). Explanation of Benefits (EOB) a statement provided by UnitedHealthcare to you, your Physician, or another health care professional that explains: the benefits provided (if any); the allowable reimbursement amounts; any other reductions taken; the net amount paid by the Plan; and the reason(s) why the service or supply was not covered by the Plan. Health Statement(s) - a single, integrated statement that summarizes EOB information by providing detailed content on account balances and claim activity. HRA - Health Reimbursement Account or HRA. It is an IRS section 105 and 106 account that follows standard regulations and tax benefits for such accounts. It can only be used for qualified medical expenses. HRA Access Point the initial amount you must pay each calendar year for Covered Health Services before you receive your HRA Benefit Dollars in your HRA. The Plan will begin paying Benefits once you have satisfied the HRA Access Point. You must still satisfy the Annual Deductible. The HRA Access Point is shown in the first table in Section 5, How the HRA Plan Works, under the heading How much money is allocated to your HRA Employer Contributions. HRA Eligible Expense an expense that you incur specific to health care on or after the date you are enrolled in the HRA Plan and include the following: (i) an eligible medical expense as defined in Section 213(d); (ii) that is an Eligible Expense as defined in your medical plan COC; (iii) a medical expense not paid for under your active medical Plan as it represents your portion of responsibility for the cost of health care such as the Annual Deductible and (iv) a medical expense not reimbursable through any other plan covering health benefits, other insurance, or any other accident or health plan. Physician any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by law. Please note: Any podiatrist, dentist, psychologist, chiropractor, optometrist or other provider who acts within the scope of his or her license will be considered on the same basis as a Physician. The fact that a Provider is described as a Physician does not mean that Benefits for services from that Provider are available to you under this Plan or any health plan. Pharmaceutical Product(s) FDA-approved prescription pharmaceutical products administered in connection with a Covered Health Service by a Physician or other health care provider within the scope of the provider's license, and not otherwise excluded under the Policy. 18 SECTION 7 - HRA GLOSSARY
Plan The Health Reimbursement Account portion of the Tulane University Welfare Benefit Plan. Plan Administrator Tulane University or its designee. Plan Sponsor Tulane University. Policy the entire agreement issued to Tulane University that includes all of the following: The Group Policy. The Certificate of Coverage (COC). The Schedule of Benefits. The Tulane University's application. Riders. Amendments. These documents make up the entire agreement that is issued to the Tulane University. Provider a health care professional or facility operating as required by law. Sickness physical illness, disease or Pregnancy. 19 SECTION 7 - HRA GLOSSARY
SECTION 8: HRA ADMINISTRATIVE INFORMATION: ERISA What this section includes: Plan administrative information, including your rights under ERISA. This section includes information on the administration of the Plan, as well as information required of all Summary Plan Descriptions by ERISA as defined in the Section, Glossary. While you may not need this information for your day-to-day participation, it is information you may find important. Plan Sponsor and Administrator Tulane University is the Plan Sponsor and Plan Administrator of the Tulane University Welfare Benefit Plan and has the discretionary authority to interpret the Plan. You may contact the Plan Administrator at: Plan Administrator HRA Plan Tulane University 200 Broadway Suite 120 New Orleans, LA 70118 (504) 247-1777 Claims Administrator UnitedHealthcare is the Plan's Claims Administrator. The role of the Claims Administrator is to handle the day-to-day administration of the Plan's coverage as directed by the Plan Administrator, through an administrative agreement with the Company. The Claims Administrator shall not be deemed or construed as an employer for any purpose with respect to the administration or provision of Benefits under the Plan Sponsor's Plan. The Claims Administrator shall not be responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor's Plan. You may contact the Claims Administrator by phone at the number on your ID card or in writing at: United HealthCare Services, Inc. 9900 Bren Road East Minnetonka, MN 55343 Agent for Service of Legal Process Should it ever be necessary, you or your personal representative may serve legal process on the agent of service for legal process for the Plan. The Plan's Agent of Service is: Agent for Legal Process - Plan Tulane University 200 Broadway Suite 120 20 SECTION 8 - HRA ADMINISTRATIVE INFORMATION: ERISA
New Orleans, LA 70118 (504) 247-1777 Legal process may also be served on the Plan Administrator. Other Administrative Information This section of your SPD contains information about how the Plan is administered as required by ERISA. Type of Administration The Plan is a self-funded welfare Plan and the administration is provided through one or more third party administrators. Plan Name: Plan Number: 501 Employer ID: 72-0423889 Plan Type: Tulane University Welfare Benefit Plan Welfare benefits plan Plan year: January 1 December 31 Plan Administration: Plan Contributions: Source of Benefits: Self-Insured Company Assets of the Company Your ERISA Rights As a participant in the Plan, you are entitled to certain rights and protections under ERISA. ERISA provides that all Plan participants shall be permitted to: receive information about Plan Benefits; examine, without charge, at the Plan Administrator's office and at other specified worksites, all plan documents including pertinent insurance contracts, collective bargaining agreements (if applicable), and other documents available at the Public Disclosure Room of the Employee Benefits Security Administration; and obtain copies of all Plan documents and other Plan information, including insurance contracts and collective bargaining agreements (if applicable), and updated Summary Plan Descriptions, by writing to the Plan Administrator. The Plan Administrator may make a reasonable charge for copies. You can continue health care coverage for yourself, Spouse or Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. Review this Summary Plan Description and the Plan documents to understand the rules governing your COBRA continuation coverage rights. 21 SECTION 8 - HRA ADMINISTRATIVE INFORMATION: ERISA
In addition to creating rights for Plan participants, ERISA imposes duties on the people who are responsible for the operation of the Plan. The people who operate your Plan, who are called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your Employer, your union, or any other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining a Plan Benefit or exercising your rights under ERISA. You will be provided a certificate of creditable coverage in writing, free of charge, from UnitedHealthcare: when you lose coverage under the Plan; when you become entitled to elect COBRA; when your COBRA coverage ends; if you request a certificate of credible coverage before losing coverage; or if you request a certificate of credible coverage up to 24 months after losing coverage. You may request a certificate of creditable coverage by calling the toll-free number on your ID card. If you have creditable coverage from another group health plan, you may receive a reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan. Without evidence of creditable coverage, Plan benefits for the treatment of a preexisting condition may be excluded for 12 months (18 months for late enrollees) after your enrollment date in your coverage. In addition to creating rights for Plan participants, ERISA imposes duties on the people who are responsible for the operation of the Plan. The people who operate your Plan, who are called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your Employer, your union, or any other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining a Plan benefit or exercising your rights under ERISA. If your claim for a Plan Benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. See Section, Claims Denials and Appeals, for details. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the plan document or the latest annual report from the Plan, and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent for reasons beyond the control of the Plan Administrator. If you have a claim for Benefits, which is denied or ignored, in whole or in part, and you have exhausted the administrative remedies available under the Plan, you may file suit in a state or federal court. In addition, if you disagree with the Plan's decision or lack thereof 22 SECTION 8 - HRA ADMINISTRATIVE INFORMATION: ERISA
concerning the qualified status of a domestic relations order, you may file suit in federal court. If it should happen that the Plan's fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees; for example, if it finds your claim is frivolous. If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or write to the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W. Washington, DC 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at (866) 444-3272. The Plan's Benefits are administered by Tulane University, the Plan Administrator. UnitedHealthcare is the Claims Administrator and processes claims for the Plan and provides appeal services; however, UnitedHealthcare and Tulane University are not responsible for any decision you or your Dependents make to receive treatment, services or supplies you receive from providers. UnitedHealthcare and Tulane University are neither liable nor responsible for the treatment, services or supplies you receive from providers. 23 SECTION 8 - HRA ADMINISTRATIVE INFORMATION: ERISA
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